Zombie Cruise Ship Virtual Escape Room for POCUS Pulmonary: Scan Your Way Out

Audience Targeted audience could be learners in medical field with basic knowledge of point-of-care ultrasound (POCUS), pulmonary and emergency medicine for example, medical students, emergency medicine residents (1st–3rd year), emergency physicians at all level of trainings, or emergency medicine physician’s assistants. Introduction Point-of-care ultrasound (POCUS) is rapidly becoming an essential part of emergency medicine and patient care .1,2 POCUS can provide more detailed clinical information when used in conjunction with a physical examination, overall aiding clinicians’ decision-making capacity.3 POCUS also proves a cost-effective tool in reducing the number of advanced imaging studies ordered and unnecessary patient radiation exposure.3,4 Performing POCUS has also proved beneficial for patient satisfaction because it increases the amount of face-to-face time spent with the patient while also providing live imaging interpretation during the emergency department visits .3,5,6 POCUS-Pulmonary can also create a safer environment for both medical staff and patients during the COVID-19 pandemic.6 Performing POCUS-Pulmonary on suspected COVID-19 patients can limit the number of patients receiving thoracic CT studies to confirm COVID-19 related pneumonia.6,7 Performing POCUS-Pulmonary reduces the number of patients transferred between the radiology department and the emergency department, significantly reduces overall possible COVID-19 exposures, and reduces equipment cleaning time.6 Given the overall reduction of advanced imaging studies ordered, CT scanners would be more readily available for critical care patients, such as trauma or other hemodynamic instability.6 Emergency providers practicing in rural areas with limited resources may benefit from the use of POCUS -Pulmonary, facilitating better patient care at decreased exposure-rate, cleaning cost, and overall increase in patient satisfaction given more bedside patient-provider communication.6–8 POCUS-Pulmonary is a crucial clinical skill for emergency medicine providers everywhere.6,8 Clinicians should be able to perform POCUS-Pulmonary, interpret image findings, and develop a treatment plan promptly.9 Educational Objectives By the end of performing the Zombie Cruise Ship Virtual Escape Room, learners will be able to: 1) recognize sonographic signs of A-line, B-line, Barcode sign, Bat sign, Seashore Sign, Plankton sign, Jellyfish Sign, Lung point, lung lockets, and Lung pulse; 2) differentiate sonographic findings of pneumothorax, hemothorax, pneumonia, COVID 19 pneumonia, pulmonary edema, and pleural effusion from normal lung findings; 3) distinguish pneumonia from atelectasis by recognizing dynamic air bronchogram; and 4) recognize indications for performing POCUS pulmonary such as dyspnea, blunt trauma, fall, cough and/or heart failure. Educational Methods This group-based learning program was designed for use in virtual meetings, lectures, and in small-group learning activities, such as didactic and EM conferences. A Google form was used to create a virtual escape room for learners in which they had to take quizzes to advance to the next level. Learners may enact teamwork through discussion and group effort, or respond individually to ultrasound pulmonary questions. Research Methods Learners will take pre and post-test assessment to compare the learners POCUS-Pulmonary knowledge before and after small group, virtual escape room learning. All participants in the virtual escape room game are given a pre and post-test assessment comprised of seventeen total questions: two questions asking the participant's training level, and fifteen POCUS-Pulmonary questions. Pre and Post-test questions are identical; however, the participants' answers to the pre-test assessment are not revealed to them on completion. Instead, participants receive a letter grade on completing the pre-test assessment. Participants complete the pre and post-test assessments over fifteen minutes allotted before and after the virtual escape room. Upon completing the post-test assessment, a letter grade and the correct answers were given to the participants. Results Twenty-four emergency medicine resident physicians (PGY 1–3)) participated in the Zombie Cruise Ship Escape Room pre-test, while a total of twenty-three resident physicians participated in the post-test assessment. The pre-test data showed an average of 10.33 points, compared to post-test data, which showed 11.91 points. There was an improvement of two points on the median score with a median pre-test score of 10 vs. the post-test median of 12. Discussion The virtual zombie cruise ship experience proved a practical and useful tool in increasing overall participants' interest in POCUS pulmonary during the COVID-19 pandemic. Participants had higher retention after actively discussing and researching the most up-to-date clinical information during the virtual and inperson small group meetings. The game encouraged participants to make decisions quickly. This pace created a fun competition between participants who genuinely enjoyed the learning experience even during the COVID-19 pandemic via Zoom/Google Meet virtual conferences. By creating a virtual escape learning tool, learners can experience teamwork-based learning without concern for group size limitations during the pandemic. Topics Sonographic findings of pneumothorax, hemothorax, pneumonia, COVID-19 pneumonia, pulmonary edema, pleural effusion, normal lung, A-line, lack of A-line, presence of B-line, Lung sliding, M mode, dynamic air bronchogram, lung rockets, Bar code Sign, Bat Sign, lung pulse, lung point, hepatization, Seashore Sign, Plankton Sign, Jellyfish Sign, and subpleural pulmonary consolidation


Linked objectives and methods:
The Zombie Cruise ship scenario's goal was to measure the efficacy of small group-based distance learning programs for POCUS Pulmonary during the COVID 19 pandemic. This virtual escape room was created to make the virtual learning experience fun and engaging during the COVID-19 pandemic and was motivated by a desire to decrease Zoom meeting and Google meeting fatigue. Students at all levels were isolated during the COVID-19 pandemic, at no small detriment to their mental and educational pursuits. This activity was intended to inspire distanced learners through online human interaction as if they could physically play games together.
All participants should take the pre-test prior to entering the Zombie Cruise Ship Virtual Escape Room. This pre-test was designed to measure the learners' knowledge of POCUS pulmonary and to prepare for the virtual escape room questions. Learns will be able to recognize their lack of knowledge in POCUS pulmonary which will encourage learners to engage more in the session to fill in their knowledge gaps. After escaping the Zombie Cruise Ship, the learners should take the post-test. The pre-and post-test questions are the same questions. They are designed to measure how much learners have learned from participating in the virtual escape room.
Working through the Zombie Cruise Ship Escape Room allows the learners to answer questions and work through cases that will teach each of the objectives. They will identify the pulmonary ultrasound findings from short video clips within the virtual escape room (objective 1). Differentiate sonographic findings of pneumothorax, hemothorax, pneumonia, COVID 19 pneumonia, and pulmonary edema from normal lung findings as the participants decide to help virtual cruise ship guests who are in need of medical assistance either due to a chronic medical condition, acute illness and/or trauma (objective 2). Learners must recognize pathologies from the POCUS pulmonary video clips and choose appropriate medical treatment in each scenario (objective 3 and 4). The escape room is designed to use the portable ultrasound to evaluate each complaint from virtual cruise ship guests to be able to either provide medical treatment to save the guests or to escape from the zombies.

Results and tips for successful implementation:
The Zombie Cruise Ship scenario is best implemented through either a Zoom meeting or in physical small group meetings.
A small group of 5 to 10 learners in one Zoom meeting is ideal. The learners must turn their video on and be able to type answer choices. The learners will open the zombie cruise ship link (https://forms.gle/ec1ErE6niPt2RDQPA) on their computer. The instructor should pick a learner to read the question, ask participants to type their answers, and pick the most answered choice. The instructor should pick different learners to read the next question. The instructor should also let the learners discuss each other by letting them unmute and freely type on the chat. After the post-test, the instructor can review questions together and summarize learning points.
A small group of five-six learners can do a physical meeting. Each group will need one instructor to encourage every participant to finish on time. The instructor should not help with any questions while learners are solving the zombie escape room. Each group can have either one computer for each participant or one computer per group of learners. If the group has only one computer, learners can gather around the computer and solve the questions together. If the group has an individual computer, the learners can only move onto the next questions after everyone agrees with the best answer. It is encouraged to allow the learners to struggle on questions and for the instructor to provide elaboration after learners have selected the correct answer.
All participants in the virtual escape room game are given a pre and post-test assessment comprised of seventeen total questions: two questions asking the participant's training level, and fifteen POCUS-Pulmonary questions. Pre and Post-test questions are identical; however, the participants' answers to the pre-test assessment are not revealed to them on completion. Instead, participants receive a letter grade on completing the pre-test assessment. Participants complete the pre and post-test assessments over fifteen minutes allotted before and after the virtual escape room. Upon completing the post-test assessment, a letter grade and the correct answers were given to the participants.
Twenty-four emergency medicine resident physicians (PGY-1 through PGY-3) participated in the Zombie Cruise Ship Escape Room pre-test, while a total of twenty-three resident physicians participated in the post-test assessment. The pre-test data showed an average of 10.33 points, compared to post-test data, which showed 11.91 points. There was a two points improvement of the median score with a median pre-test score of 10 vs. the post-test median of 12.
Additionally, the virtual escape room was presented at two different medical schools for third and fourth-year students via Zoom conference meetings: During these sessions, we learned that participants stayed focused during the entire small group session. This encouraged participants to actively discuss their clinical decision making process based on the zombie cruise ship scenarios. One of the questions in the zombie cruise ship scenario had two correct answers. However, to encourage more discussion, the question did not indicate that there were two correct answers. The participants engaged more with the small group activity by  o Plankton sign -Demonstrates pleural effusion. In large effusions, a lung that has collapsed under the pressure of the fluid collections may be seen sliding in a fluid motion with the patient's respiratory efforts o Lung point -highly specific ultrasound sign of pneumothorax. The junction between sliding lung and absent sliding is known as lung point. o Lung Pulse -rhythmic movement of the pleura in synchrony with the cardiac rhythm. Parietal and visceral pleura oppose one another, and so its presence rules out a pneumothorax.